Provider Demographics
NPI:1619923117
Name:RUKAVINA, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RUKAVINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636493
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6493
Mailing Address - Country:US
Mailing Address - Phone:513-981-5130
Mailing Address - Fax:513-981-5015
Practice Address - Street 1:1100 RICHMOND ROAD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-0524
Practice Address - Country:US
Practice Address - Phone:606-723-7706
Practice Address - Fax:606-726-9410
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY22686207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64226863Medicaid
C69113Medicare UPIN
KY64226863Medicaid